Information Collection List

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.
Additional Documentation and Certification	Modified	30	23	0	Form	3
					Form	1
					Form	1
Authorization for Use or Disclosure of Health Information Form	Modified	100	200	0	Form and Instruction	2
					Form	1
					Form and Instruction	1
Benefits Package and Supporting Documentation	Modified	30	4	0	Instruction
					Instruction
					Instruction
					Form	4.1
					Form	4.2
					Form	4.3
					Form	4.4
					Form	4.5
					Form	4.6
					Instruction
					Instruction
					Instruction
					Form and Instruction	Attachment 2
					Form and Instruction	Attachment 2
					Form and Instruction	Attachment 3
					Form and Instruction	Attachment 3
					Instruction
					Instruction
					Instruction
					Instruction
					Instruction
					Instruction
					Form and Instruction	Attachment 2 - Estate
					Form and Instruction	Attachment 2 - Estate
					Form and Instruction	Attachment 3 - Estate
					Form and Instruction	Attachment 1 - Survivor
					Form and Instruction	Attachment 1 - Survivor
					Form and Instruction	Attachment 2 - Survivor
					Form and Instruction	Attachment 2 - Survivor
					Form and Instruction	Attachment 3 - Survivor
Countermeasures Injury Compensation Program Request Package	Modified	100	1100	0	Form	1
					Form and Instruction	1A
					Form and Instruction	1
					Form and Instruction	1
Total burden requested under this ICR:		260	1327	0
To view an IC, click on IC Title